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General NPI Number Information
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NPI Number | 1235508342
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Entity Type | Organization
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Legal Business Name | EAST MISSISSIPPI ORAL & FACIAL SURGERY, LLC
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Dates
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Enumeration Date | 09/18/2015
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Last Update Date | 03/18/2016
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Provider Practice Location Address
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Address Line | 1212 24TH AVENUE
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City | MERIDIAN
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State | MS
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Zip | 39301
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Country | US
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Telephone | 601-286-5240
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Fax |
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Provider Business Mailing Address
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Address Line | 1212 24TH AVENUE
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City | MERIDIAN
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State | MS
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Zip | 39301
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Country | US
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Telephone | 601-286-5240
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ASIF A LALA
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Credential | DMD, MD
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Telephone | 912-675-8468
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | 3785-15
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License Number State | MS
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